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S_N BY: S'ECTFUM EXPLOFi\710v, 5;21 14:5E; <br /> WELL PERMIT APPLICATION FOAM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD). ., _ <br /> ✓�(/� 304 E. Weber, Third Moor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ApOi�catirn i5 hereb7 made to S,tr� roJyw,t(ioUnr/fr•r a pr:mit tp construct arlClor rnstan the worx cescnaed Th!s appocr3t.o�:rs r„34r'. u,ra,rpf�nni.r wr,:i <br /> �.an,Icapwn r-:oanly D-r>.lirprnent Time.i.hnpt?r A 1?1F In.n t^? E<crdarr c(if 3=In.lua Iu n C41n+,PJC�Ii tt=altll Swvkes.En':rro�^ent3;f-e]!a rr.ie,c:` <br /> Assessrr <br /> /gyp s-pC}S�`cyN `��'2�6 <br /> WELL L.acation_ dv..1 _.___..... .-_I'p..._..._............_.... - <br /> �-..._—_.. _ ...n]er_a��SR Y -- <br /> Pi2JF'EKTY llwne;RIG Ae1J AlP1ieG�On/ _ .N Ga'2N(c�l J� Si0�1<-TZ)nJ <br /> v r.x��, X65 w t�,W� �� _�..rs;'tKkTDN._r•9s�b5 i cn5ta�6$'•, r.;::tea..�h�� —g,� <br /> r <br /> C-57 Contiactorsfrtc�Q <br /> _ �p/��DZ:JtA ANs+r.`ScSAGre�cl�lt•{- w�tPr-rS� _t:i:y�Cp•E-O.J t.,.n,F{GrY0�3�.., rtrrt�$�g'�g <br /> Consultant!5Lt, <br /> GIS cocr.±rates. <br /> YVORK TO BE.PERF:JRM€D_ <br /> �Nf=fV WELT_iYHORIM(:(t`�'1,G6c)C�u[)ts�.tIYC�KUi%��Dlt_F:,FtaNr'-A��=�E4 G'iTl-1ER•i Q CF:rTR':St'-!C:.v�r,rC•iae:p'ry o_•�ow• <br /> SO1 BORING it .7VF.R SORE <br /> -:'REaSURL is FKCI:' <br /> '/JLLL� MWI MWS. �"tw3'.._.. t... � <br /> �.....,.__ <br /> •Ot{tort .... .........__........... — ---.._..----- <br /> TYPE.OF WELL INSTALL --- TYPE COhSTR:ICTICN SPECIFICATIONS tt <br /> 1AONITC•RINi$ ULLliW (L1: Ulf U'r 8::�k=Fi(�LE .8._.-:..__PAtt't(LE G.EING, G Yc5 Vi:) �'cLl.Crlt ltiL <br /> ]F'X'*RRC1 K)N Q AIR.HANIME.F.:OR-VEN Ch :NG TNI CKNESSa� .4_P TYPE Of CA-ciNC, 0 511-k i. <br /> VAPOR [I MUCi P.OTArtY DEP-H OF GROUT sEi.�_ lS 1KEh11E'TYP= <br /> 0 AIR SPARCF Q r kJSH POINT G+tC.+ir Ss i PUPAF't:; C Yt No (MOTE: MAXIMUM FREE-FALL DEPTH !S30') <br /> f30L.TcD TFiAF"r' .R:iX nr STCvE P;cF. <br /> p SOIL BORING 0 HAND AUGER P.�'t't:c>.x. is:�r(Jr+t�utrtrt_ __...___.._...� C <br /> nTHE, . Q OTHER--....-... L:0NL)UC(OH CAS!NG PROPCSFOl.OJ0--t rf YES Inst 5pec:`1:1a:ns htr:e. <br /> COMMENTS:_—........_..................------ ---- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I heroay Certify that I h:44e praparad th:s ar-pl:c•,atrnr and that t:,a w,-k Aie:l t.@ 70no:n icCJrdanea w.tn San Jcaqu!n County OfCv1a-i_=s M 4!e Laws.and RuIC-5. <br /> an;,4egutaaons of the San doaquo Co%;no Han'.Eowl-le ur t1c9r'W1 49Q'It S slr e <br /> uf-ire ;ertiflei the foltowmg "I c j!tiiy that in the prriormartce ur a e vark <br /> fpr wh!ch this pertnit is issued,f shad no!employ persorTs subject tc WOPKEPS'COMPENSATION Laws o. California - <br /> eo^•tract:nc signature ertitics!hr fo!tzxir.q 'f rr.r:!/Mvr is thn ptrf::rrnhnrr of:heµOrk i_r Try+Ch this wrlymt is r93w1 f.!Sifc7li en:Ph :gerso:s-:suni�r'1 <br /> WORKERS'COMIP °A77ON Lows of fuima <br /> T EAP LlCAtV7 M EQR�CiNG HRS lei ADVANCE FOR.ALL RfiQUiRED1. <br /> tl�1SPEC IONS. <br /> S'ignod x /0/L 3 Cj—_._......__.._. <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: 1611 -34qZ_ <br /> DEPARTMENT USE ONLY0 2f-( 9 0 <br /> � <br /> Applicat.rin Accepts=A 8y� Ua'a tssur,: r (�/r <br /> Groat Inspection By----- --— -..................._...n'tr..,_._....-- F!r.al Inspection Esq .OMPLIt <br /> Dostruction Inspection By Dot, 7, <br /> COMMENTS t CONDITIONS: _ _....._..... <br /> __....._.-.--._..—_—..............._,..: <br /> ACCOL:NTMG ONLY AID# � EAC: <br /> PE CODES FEE INTO AMOUN; REMIT 1'EJ I CHECK fi RECD BY DATE PERMIT+SERVICE REQUEST tt ! INVOICE ! <br /> C-57:ITCT:NSED Cl�4TRAC:TnIt.i�lI35T SIGN LICENSE&�` RS'CC�MPr'�i:iAl'ION UECLARATIO�i <br /> UNIT IV•6!23/99/Sign bkpg/MI <br />